REG NASA-LLIS-5916-2011 Lessons Learned Pad A Mobile Launch Platform (MLP) Ladder Mishap.pdf

1、Public Lessons Learned Entry: 5916 Lesson Info: Lesson Number: 5916 Lesson Date: 2011-06-23 Submitting Organization: KSC Submitted by: Amber Porter Subject: Pad A Mobile Launch Platform (MLP) Ladder Mishap Abstract: On 20 May 2008, a team of Structures Technicians (STs) were preparing Launch Pad 39A

2、 for the launch of Space Shuttle STS-124. Part of the launch pad preparation involved covering bare-metal components on the MLP Pedestals with Molykote grease, plastic sheeting, and securing with plastic tape, to protect from deluge water and acid created from burning solid rocket propellant. At app

3、roximately 10:00 a.m., a structures Technician Lead (STL) fell from the Pedestal 3 fixed ladder while performing this task. It is important to emphasize in periodic training that workers maintain a three point contact with ladders as well as be aware of their surroundings and complete work safely. D

4、escription of Driving Event: Launch Complex LC-39A was being prepared for the launch of Space Shuttle mission STS-124. Part of the preparation included protecting bare metal components on Mobile Launch Platform (MLP) Pedestals from the corrosive effects of deluge water and acid produced from the bur

5、ning solid rocket boosters. Structures personnel were tasked with performing this work, including applying a lubricant known as Molykote to exposed components, then wrapping them in plastic, and securing the plastic in place with vinyl tape. While performing this protective task on 20 May 2008, at a

6、pproximately 10:00 a.m., a Structures Technician Lead, hereinafter referred to as STL, fell approximately eight (8) feet from a fixed ladder on MLP Pedestal 3, to the pad surface. During the fall, STL pushed away from the fixed ladder to clear ladder obstructions below. STLs feet landed approximatel

7、y six (6) feet away from the base of the ladder, onto the Crawler-Transporter (CT) trackway with the left heel striking a two (2) inch high metal tab used to secure plywood sheets to the CT trackway. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Le

8、sson(s) Learned: When using ladders it is important that workers maintain a three point contact with the ladder as well as be aware of their surroundings so that what ever task is being completed can be done safely. Recommendation(s): Contractor employees receive periodic training in the hazards ass

9、ociated with climbing fixed ladders and procedures to minimize the associated hazards, including the use of hoisting equipment. Contractor provide employees with more comprehensive training on the proper use of PPE during the application of Molykote. Remove all non-compliant MLP Pedestal fixed ladde

10、rs on LC-39A, LC-39B, MLP Park Site, and the Vehicle Assembly Building (VAB) from service (tagged out), and permanently remove from pedestals. Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-Install protective covers on MLP Pedestal upper boss and up

11、per spherical yoke. Evidence of Recurrence Control Effectiveness: N/A Documents Related to Lesson: click to view mishap report Mission Directorate(s): N/A Additional Key Phrase(s): Safety and Mission Assurance.Maintenance Additional Categories.Accident Investigation Additional Categories.Facilities Additional Categories.Human Factors Additional Info: Project: N/A Approval Info: Approval Date: 2011-10-03 Approval Name: mbell Approval Organization: HQ Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-